Innovations in technology have revolutionised almost every aspect of life, and health care and medical education are no exception. Online learning (or e-learning) is a perfect panacea for the current times, with its easy access, affordability, flexibility, and learning pedagogy.  However, students often find online learning boring and unengaging, with a lack of personal attention and two-way interaction. Thus, the exploration of unconventional online learning methods, such that they are creative, student-centred, interactive, and relevant, is the way forward to make the learning process more effective and efficient.
The All India Institute of Medical Sciences, World Health Organization Collaborating Centre for Training and Research in Newborn Care (WHO-CC AIIMS) has been a long-time innovator of modern learning methods. Our team previously published research on the efficacy of internet-based distance learning to enhance the skills and knowledge of in-service nursing professionals ; and the efficacy of an app on standard treatment protocols  to improve the knowledge and skills of both nurses and doctors [4,5,6]. Students often want two-way interaction, which sometimes may be difficult to implement in this app-based, self-directed learning. However, if the app can be interactive and group-based with effective instructions, it is likely to improve the learning process.
We hereby describe another innovative, interactive method of mobile phone e-learning, which is suitable for regions with diverse cultures and practices. Its effective online instructions facilitate feedback from learners, encouraging them to ask questions, and thus broadening their understanding. The content used for the course was a multimodal educational package. The development methodology and results of this package are under publication.
Harnessing the Telegram for Online Discussion
Telegram is a freeware, cross-platform, cloud-based instant messaging software and application service that can be harnessed for interactive and asynchronous e-learning. One can create a large group with a maximum 200,000 members, upload study documents and videos without compromising quality (up to 2GB), and conduct anonymous polls and quiz assessments.
The course participants included in-service nurses from India (n=4,512), Bhutan (n=25), Bangladesh (n=25), and United Arab Emirates (UAE) (n=61), mentored by 62 facilitators (both paediatricians and neonatal nursing champions). 62 facilitators and 4,623 nursing professionals involved in providing neonatal care (from public and private health care sectors) from 19 states across India and South East Asia Region participated in this interactive course on Telegram. The standardised learning resources from the facility based preterm care package (available at www.pretermcare-eliminatingrop.com) included webinars, videos on practical procedures in a newborn intensive care unit (NICU), and posters. Ten modules were covered over 10 weeks, which included:
- delivery room care
- good nutrition
- developmentally supportive care
- kangaroo mother care
- optimal oxygen therapy
- optimal continuous positive airway pressure
- less systemic infections
- less exposure to blood products, and
- follow up care pertaining to retinopathy of prematurity
The contents have been previously pilot-tested and are in countrywide use for blended learning (face-to-face and online).
Unique Features of Telegram
Live chatting, though occasionally asynchronous, is a great way to replicate the real-time discussions that take place in any classroom cohort. The platform (Telegram) allows participants and facilitators to communicate and brainstorm around a topic of the week and the resources posted. The chat provides information for quick revision and clarification of doubts for the learners. Live discussions and brainstorming are engaging, and the learner gets personal attention (a feature that app- and website-based learning often lack). In addition, Telegram-based live chatting provides flexibility and accessibility. Students can learn anytime and anywhere, at their own pace, using the resource materials and raising queries via the chat function. We had an inherent advantage with standardised resources and uniform messages already developed and pilot tested. Since we decided to reach out to a maximum number of nursing colleagues, over such a wide geographical area, the availability of standardised resource material was extremely beneficial.
The format of the course included (in this order):
- loading content on two defined days of the week,
- mentor-monitored discussions on the platforms,
- end module weekly assessments on the topic of the week, and
- finally a live session on a defined day for raising queries to be answered live by mentors and group faculty (of the week), and revision of key messages. A third-party bot on Telegram (Quiz Bot) created quizzes, with responses tracked in real-time (under publication).
In terms of timing, we retained the attention and interest of the participants for 10 weeks. There were more than 1,000 chats and discussions through the very last day of the course. 2,650 participants (57%) completed the assessment quizzes in the first four weeks, and we sustained 2,100 responses (45.4 %) from week five to week 10.
We took interim feedback from both the faculty and participants, and made modifications in the discussions. End of course feedback was also taken, based on the Likert scale.
The platform (Telegram) did have some of the inherent limitations of online learning, such as connectivity issues, lack of face-to-face interactions, and language barriers in a few states. However, we tried to combat these by hosting live video sessions via YouTube streaming, where the facilitators of the week answered the queries live through video chat. The recordings of these sessions were made available to the participants to be viewed later in case of connectivity issues.
Future Vision of the WHO-CC AIIMS
We envisage that the current course on the Telegram platform has strong potential to reach a larger group of learners in different countries. This would require local champions ready to mentor their own health professionals with context-specific guidance. The prerequisites and attributes essential from the learner’s perspective include self-discipline and motivation for self-directed learning. The facilitators need to be available for timely responses to keep learners engaged.
Preparing standardised resource content and assessments, vetted by a group of experts, would ease the implementation of courses on this platform. Focussed discussions on selective topics of national importance, like malnutrition, pneumonia, tuberculosis, and neurological disorders, can be easily initiated to spread a uniform message to learners across the country.
We are currently replicating the same course on the Telegram platform for nearly 600 doctors (paediatric post-graduate residents, fellows in neonatology from government and private institutions, and paediatricians from Special Newborn Care Units) with over 70 national experts in neonatology. The course has nominal registration fees of $15, and is free of charge for nurses.
The authors declare that they have no competing interests.
The authors are grateful to all faculty from the National Neonatal Forum of India (NNF India) and the Indian Association of Neonatal Nurses (IANN) for endorsing the preterm package and app (available as PretermCare on iOS and as WHO CC PTC on Android). Both organisations were instrumental in nominating faculty and the enrolment of participants for the e-course. We also thank the Queen Elizabeth Diamond Jubilee Trust U.K. for supporting the development of the standardised package for preterm care for prevention of retinopathy of prematurity.
- Song L., Singleton E. S., Hill J., Koh M. H. (2004). Improving online learning: Student perceptions of useful and challenging characteristics. The Internet and Higher Education, 7(1), 59–70
- Thukral A, Sasi A, Chawla D, Datta P, Wahid S, Rao S, Kannan V, Veeragandam A, Murki S, Deorari AK. Online Neonatal Training and Orientation Programme in India (ONTOP-IN) –the way forward for distance education in developing countries. J Trop Pediatr. 2012 Dec;58(6):486-9
- App available on Google Play (android) as AIIMS-WHO CC STPs and on iOS (Apple) as SickNewborn.
- Thukral A, Joshi M, Joshi P, Prakash V, Adkoli BV, Deorari AK. Apps for management of sick newborn: evaluation of impact on health care professionals. J Trop Pediatr 2014; 60:370-6.
- Prakash V, Thukral A, Sankar MJ, Agarwal R, Paul VK, Deorari AK. Efficacy and acceptability of an “App on sick newborn care” in physicians from newborn units. BMC Med Edu, 2016;16:8